Glycemic Control at Southwest Washington Medical Center

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Glycemic Control at Southwest Washington Medical
Center

• Implementing a Quality Improvement Blueprint
• Chris Hogness, MD, for the SWMC Glycemic Control
  Team

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Trying to move from guidelines to the care of
specific patients without making a mess
Heifetz, Leadership Without Easy Answers
(Cambridge Harvard University Press, 1994)
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Accomplishments from spring 2005 to the present

• Team culture
• High level institutional support
• Metrics
• Standardized order sets
• Physician and staff training
• Progress towards specific goals
• Regional networking

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TEAM Approach to the Treatmentof the
Hospitalized Diabetic Patient
Pharmacist
Physician
Primary Care Nurse
Dietitian
Endocrinologist
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Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
Health Services Research, 200641(4 Part
II)1599.
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Where to begin?

• Small multidisciplinary group
• Physicians
• Nursing
• Pharmacy
• Nutrition
• Review literature and best practices
• Networking with leading institutions
• Assess current practices
• Pick a glycemic control project

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Garnering high level institutional support

• Hospital Executive Team presentation March 2006
• Evidence and local application
• Quality Committee of Hospital Board of Trustees
  presentation May 2006
• Board of Trustees adopts glycemic control as SWMC
  Quality Goal June 2006
• Hospital Foundation funding Sept 2006

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Multidisciplinary committee membership

• Physician champion
• Medical staff
• Pharmacy
• Nursing
• Nutrition
• Laboratory
• Information Systems
• Food Services
• Quality Care Resources
• Education
• Administration

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Multidisciplinary committee function

• Coordination and evaluation of inpatient glycemic
  control activities
• Protocol implementation
• Staff education
• Compilation and review of data
• Monthly meetings

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Steering committee

• Smaller group provides administrative support
• Membership
• Key executive leaders
• Directors of pharmacy, nursing, nutrition
• Physician champion
• Lead pharmacist/CDE for glycemic control
• Meets every other month
• Review outcomes, financial/staffing support,
  reporting to hospital board of trustees

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Glycemic Control Team daily management of
patients

• 1.4 FTE Pharmacy 8 hrs/day, 7 days/week
• 1.4 FTE CDE 8 hrs/day, 7 days/week
• Physician back-up call rotation
• Clerical support

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Metrics

• Format
• Glucometer based
• Patient centered
• Uses
• Internal review/evaluation
• Glycemic control committee(s)
• Nurse unit meetings
• Physician hospitalist groups
• External comparisons
• Regional
• National

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Glycemic control at SWMC 2005
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Summary by Location (Cont.)
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Summary by Location (Cont.)
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Metrics currently tracked

• Average blood glucose level by unit
• Percent of glucometer readings in goal range
• Critical care 70-150 mg/dl
• Non-Critical care 70-180 mg/dl
• Percent of patient-monitored days in control
• No more than 1 reading outside 70-180 mg/dl for
  patients with at least 2 readings over a 24 hr
  day
• Number of patients with severe hypoglycemia
• Glucose lt 40 mg/dl

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Specific Aims

• Non-critical care units
• 80 of patient-monitored days in control (no more
  than 1 value outside 70-180 mg/dl goal range)
• Critical care units
• 80 of glucose levels in 70-150 mg/dl goal range
• Investigate all severe hypoglycemia episodes and
  decrease incidence
• Increase percent of insulin-treated patients
  basal insulin to 80
• Shorten surgical length of stay, decrease
  infection rates, decrease mortality

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Standardized insulin order sets and protocols

• Critical care insulin infusion
• August 2005 4-column protocol pilot
• March 2006 6-column revision
• Non-critical care insulin infusion
• Fall 2006 4-column protocol pilot
• Spring 2007 full implementation
• Subcutaneous insulin order set
• Pilot Fall 2005
• Multiple revisions since
• Sliding scale eliminated

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3 South Adult Insulin Infusion PILOT (backer)
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Education, education, education

• Physicians
• Nurses
• Pharmacists
• Patients
• Hospital Administration
• Board of Trustees

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Education Physicians

• Three hospital grand-rounds
• Fall 2005, Summer 2006, Fall 2006
• Individual presentations to each of four internal
  medicine hospitalist groups
• Presentations to medical staff departments
• Surgery, Anesthesia, Cardiology, Ob-Gyn Dept
  mtgs.
• All-staff Quarterly meetings
• Medical executive committee

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Education Nurses

• 3 hour didactic Caring for the Diabetic and
  Hyperglycemic Patient
• Presenters Physician, pharmacist, CDE, nurse
  educator
• 25 nurses per class
• 614 nurses trained February-March 2007
• Funded by hospital foundation
• Case review at monthly nursing unit meetings
• 20 question required annual Web-In-Service

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Education pharmacists

• Written didactic material distributed to 5
  pharmacists on glycemic control team
• On-the-job training working with physicians
  managing in-patient cases
• Rotation through outpatient diabetes clinic
• Protocols written for cross-covering night
  pharmacists

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Pharmacy Team

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Education patients

• Certified Diabetic Educators see pts with
• Hemoglobin A1C gt 8
• DKA
• New diagnosis DM
• Newly begun on insulin
• Nurses begin patient self-administering insulin
  as soon as possible in hospital stay
• Patients enrolled in diabetic education classes
  for follow-up after discharge

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Focus on perioperative care

• Surgeons request pharmacy assistance this is
  too important to leave to us
• Anesthesia department receptive
• Small group including pharmacist,
  anesthesiologist champion, hospitalist
  review/modify perioperative processes

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Holding the gains over time

• Percent of glucometer values in specific ranges
  for different units
• Percent of patient-monitored days in control
• Number of cases of severe hypoglycemia on
  specific units
• Percent of insulin treated patients receiving a
  basal insulin
• Length of stay for surgical and critical care
  patients

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Increase in appropriate insulin prescribing on
wards
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Length of stay in ICU decreases for diabetics
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while ICU length of stay increases slightly for
all patients
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Portland-Vancouver Regional Inpatient Glycemic
Control Collaborative

• September 2006 Nine hospitals attend inaugural
  meeting at SWMC
• Quarterly meetings December 2006, March 2007,
  June 2007
• Consensus on regional metrics for transparent
  data-sharing in the region
• Shared experience protocols, education,
  literature and conference information

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• Questions?